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HomeMy WebLinkAbout2026-00060359 ILLINOIS TRAFFIC CRASH REPORT Sheet 1 of 2 Sheets 01111101111 10110 II I IIIIII11111110011000 DRAC TRFD TRFC WEAT DRVA VIS VEND LGHT COLL MANY X004399355 u, 1 U21 2 4 1 u, 2 U2 1 u112 1_12 1 u, 1 U2 1 1 15 u, U2 1 *P 0119 INVESTIGATING AGENCY AGENCY CRASH REPORT NO. TRFW ' DAMAGE TO ANY ❑$500 OR LESS TYPE OF REPORT ❑ A No Injury 1 Drive Away Elgin Police Department ONE PERSON'S ❑$501-$1.500 ®ON SCENE 14 VEHICLE/PROPERTY ®OVER$1,500 El NOT ON SCENE(DESK REPORT) ® B Injury and/or Tow Due To Crash El AMENDED YR 202612026-00060359 VENT ADDRESS NO. HIGHWAY or STREET NAME CITY TOWNSHIP INTERSECTION DATE OF CRASH TIME SECONDARY CRASH 1 -n DAM ISCH RD Elgin 01:07 ® ❑ RELATED ®Y 0 N 10 04 2026 ❑AM ❑YES ®NO U1 —< _ _ g PRIVATE mo !day!yr ®PM FLOW CONDITION m FT!MI N E S W W HIGHLAND G H LAN D AVECOUNTY PROPERTY ❑Y ® N DOORING Ely #OF MOTOR El SLOW 15 t� ❑ Kane HIT&RUN ❑Y ® N WITH VEHICLES INVLD ❑ STOPPED U2 —I ® AT INTERSECTION WITH (NAME OF INTERSECTION OR ROAD FEATURE) PEDALCYCLIST®N 51 FREE FLOW # LNS 0 g DRIVER ❑ PARKED ❑DRIVERLESS 0 PED 0 PEDAL 0 EWES 0 uuv 0!CV 0 Dv DATE OF BIRTH MAKE MODEL YEAR CIRCLE NUMBER(S) Y N 0 C) 0 3 ! yr 13-UNDER CARRIAGE ©,I �._Z FIRE 0 STREET ADDRESS SEX SAFT AIR AUTOMATION LEVEL LEVEL 14-TOTAL(ALL) DISTRACTED 0 0 U2 O m F 2 SY8 ❑Y ❑STM NE CD UNK VEH. 9 AT CRASH 9 99-U 15-UNKNOWN THER9 16•TOP 3 `Distraction Value 9 ALGN 2 r CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF s, it B COM VEH 0 0 1 0 F. FIRST CONTACT 12 7_;, , _5 *II Yes.See Sidebar U1 Z Wheeling IL 60090 B 1 0 DM44162 IL 2027 REAR TELEPHONE IL D 4T1 BF1 FKOEU856416 First Chicago Insurance C ❑Y Il N U2 19 , m in EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER RSUR m Elgin Fire Same I LS97303804 1 r "o HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY,STATE,ZIP PHONE NUMBER RESPONDER D Sherman 0 Y ❑ N 2 0 g DRIVER ❑ PARKED ❑DRIVERLESS ❑ PED 0 PEDAL 0 EWES 0 NMV 0 !1 9 y 8 9 Jeep(after 198;;i)ind Cherokee 2026 00-NONE 0. Q1-_, DUE TO CRASH rg ❑ 2 x o 13-UNDER CARRIAGE 10( ) 2 FIRE 0 ® U2 C II F 2 5 SYSTEM IN 9 ENGAGED 9 15-OTHER 9,16-TOP 3 X ❑Y CIN ®UNK VEH. AT CRASH 99-UNKNOWN *Oistracton Value 9 U1 0 N CITY STATE ZIP INJ EJCT EPTH PLATE NO. STATE YEAR POINT OF i1i 4 COM VEH 0 ® COA FIRST CONTACT 11 8 7 _5 •If Yes.See Sidebar — Pingree Grove IL 60140 B 1 0 FY70650 IL 2026 I O N IL D 1C4RJKBR1T8582594 Prodressive ❑Y ®N RDEF XI EMS AGENCY PEDV PPA PPL VEHICLE OWNER(LAST,FIRST,M) POLICY NUMBER 1 = Pingree Grove Fire Same 973941903 SAC E HOSPITAL(TAKEN TO) INCIDENT IF'Y' OWNER STREET,CITY STATE,ZIP 996 < Other RESPOND O N u1 = (UNIT) (SEAT) (DOE)) (SEX) {SAFT) (AIR) (INJI (EJCTI (EPTH) PASSENGERS&WITNESS ONLY (NAME)((A.DDRESS)(TELEPHONE) (EMS) (HOSPITAL) 1 3 01 / M 2 8 B 1 0 m / / #OCCS > / / UI 2 m / / 1 0 EV MOST EVNT LOC DAMAGED PROPERTY OWNER NAME DAMAGED PROPERTY POLICE NOTIFIED TIME Did crash occur 0 Y U2 Z N 1 ® 11 4 10,04 l2026 01 07 ®pm in a Work Zone? ®N DIRP co 1 I PROPERTY OWNERS ADDRESS:STREET,CITY,STATE,ZIP PRIMARY CAUSE SECONDARY CAUSE EMS NOTIFIED TIME ❑AM If YES check one below: U1 7 C) T 0 2 0 2 23 , , ❑PM ❑Construction " 3 0 $I CITATIONS ISSUED 0 PENDING SECTION CITATION NO. EMS ARRIVED TIME 1 ❑AM 0 Maintenance U2 o ® 11 4 ARREST NAME Abreu Rivas. Mayra. D. 11-305-A 410000854 / ! El Pm SLMT o N ❑CITATIONS ISSUED PENDING SECTION CITATION NO. ROAD CLEARANCE TIME ' ❑ 45 Utility t 2 0 ARREST NAME AM T 1 r ❑❑PM 0 Unknown work zone type U1 2 2 3 0 OFFICER ID SIGNATURE BEAT/DIST. SUPERVISOR ID. COURT DATE TIME ❑AM Workers present? ❑Y 45 410-DeLeon.Jessica 901 10 ,20,2026 01 30 ®PM ®N U2 REMEMBER TO USE BLACK INK,PRESS HARD,PRINT LEGIBLY AND COMPLETE ALL REQUIRED FIELDS! A Diagram and Narrative are required on all Type B crashes, LARGE TRUCK, BUS, OR HM VEHICLE even if units have been moved prior to officer's arrival. IF MORE THAN ONE CMV IS INVOLVED,USE SR 1050A ADDITIONAL UNITS FORMS. r ----r••--, , ; A CMV is defined as any motor vehicle used to transport passengers or property and: Z } } ' 1. Has a weight rating more than 10,000 pounds(example:truck or truck trailer -< ' I • INDICATE NORTH combination):or p0 BY ARROW 2 Is used or designed to transport more than 15 passengers including the driver C } I - } r r (example:shuttle or charter bus):or 0 < <---- -•-•; II I transporting employened to es inthe course passengers5 or fewer thir emplod yment example:employee transporter} } } transporter-usually a van type vehicle or passenger car):or X L L.___a____� fV •1. 4. Is used ordesi natedtotrans rtbetween9and15 passengers,including y} } for direct compensation(example:large van used for specificpurpose):or [he driver, wvr .,,dv,.. Pe ( P 9 Pe or O L -a-___.i 'a__ I - L i. i Iany 5. Is any vehicle used to transport hazardous material(HAZMAT)that requires rii1W win) placarding(example:placards will be displayed on the vehicle). XI " OR Ir. D 1�' Not 7' to CARRIER NAME Z ADDRESS 0 V) IO CITY/STATE/ZIP g _ MOTOR CARR.ID ❑ Ita ❑ r I ❑ Notnters in Cotemm.lGaA. Not inIntrastate Comm./Other 0 USDOT NO. ILCC NO. C XI Source of above Z . • m Did HAZMAT spill from vehicle(do NOT consider FUEL from vehicle's z own tank)? 0 Yes 0 No 0 Unknown Did HAZMAT Regulations violation contribute to the crash? r ❑ Yes 0 No 0 Unknown g D -< Did Carrier Safety Regulations MCS)violation contribute to the crash?El❑ Yes II No Unknown C Was a driver/vehicle Examination Report Form completed? r HAZMAT ❑Yes 0 No ❑Unknown Out of Service ❑Yes ❑No 7 MCS ❑Yes 0 No 0 Unknown Out of Service ❑Yes ❑No C Z Form Number 0 m Xl IDOT PERMIT NO. WIDELOAD'; ❑Yes 0 No 2 TRAILER VIN 1 m co LOCAL USE ONLY TRAILER VIN 2 m v TRAILER WIDTH(S) 0-96" 97-102" >102' m TRAILER 1 ❑ ❑ 0 Z TRAILER 2 ❑ 0 ❑ O u 1 COLOR U 2 COLOR TRAILER LENGTH(S)1 ft. 2 ft. Z Gray Silver u 1 TOWED • TOTAL VEHICLE LENGTH ft. NO.OF AXLES_ DUE TO ® DISABLING DAMAGE ❑ NOT DISABLING DAMAGE DAMAGE EXTENT 3 TOWED BY/TO. Redmons/Impound Lot Garage . SELECT CODES FROM THE BACK OF CRASH BOOKLET U 2 TOWED DISABLING DAMAGE NOT DISABLING DAMAGE DAMAGE EXTENT: 3 TOWED BY/TO: DUE TO ® Redmons/Impound Lot Garage VEHICLE CONFIG._CARGO BODY TYPE_LOAD TYPE